Currently there exists no clear evidence concerning the surgical treatment of LHB lesions with either tenotomy or tenodesis. The aim of the study is therefore to evaluate elbow flexion and forearm supination force as well as the biceps muscle distalization according to both techniques in isolated LHB lesions. Consecutive patients aged 40–70 years with shoulder arthroscopies for isolated SLAP or biceps pulley lesions were prospectively randomized to arthroscopic suprapectoral intraosseous LHB tenodesis or tenotomy. Pre-, 6 and 12 months postoperatively, the SST, ASES, Constant–Murley and LHB scores were recorded. The elbow flexion force was measured in 10°/90° flexion, the supination force in neutral/pronation position. In addition, the maximum upper-arm circumference and its position relative to the radial epicondyle of the humerus were evaluated preoperatively and in follow-up. 20/22 patients (mean age 52.0 ± 8.5; range 36–63 years, 11 male) completed the follow-up. 9/20 were treated with LHB tenodesis (mean age 51.5 ± 9.5; range 37–63 years, 7 male) and 11/20 with tenotomy (mean age 52.8 ± 8.0; range 36–62 years, 4 male). The force measurements and scores showed no significant difference after 12 months. Tenodesis achieved a significant increase in force 6 months postoperatively compared to preoperatively. One tenodesis patient and three tenotomy patients showed a postoperative popeye-sign deformity. This prospective randomized study comparing LHB tenodesis and tenotomy in isolated LHB lesions has shown no significant difference in elbow flexion and forearm supination force and clinical scores after 12 months. After LHB tenotomy, there was a non-significant trend for a higher rate of popeye-sign deformities of the upper arm and biceps muscle cramps.

Biceps tenodesis versus tenotomy in isolated LHB lesions: a prospective randomized clinical trial.

Background:Open repair can be more useful than arthroscopic repair for immobile and severely retracted, large to massive rotator cuff tears. However, it is not known whether the deltoid muscle is altered after open repair or to what extent the deltoid origin remains detached after surgery.Purpose:To compare postoperative alterations of the deltoid muscle in open versus arthroscopic repair for severely retracted, large to massive rotator cuff tears.Study Design:Case-control study; Level of evidence, 3.Methods:Enrolled in this study were 135 patients who underwent surgical repair for severely retracted, large to massive rotator cuff tears and who had routine follow-up MRIs at least 6 months after surgery. Open repairs were performed in 56 cases and arthroscopic repairs in 79 cases. The detachment and thickness of the deltoid muscle at its proximal origin were recorded in 5 zones on MRI. The alterations of the deltoid muscle and postoperative integrity of the repaired rotator cuff were evaluated.Results:Part...

Alterations of the Deltoid Muscle After Open Versus Arthroscopic Rotator Cuff Repair

The long head of the biceps tendon is widely recognized as an important pain generator, especially in anterior shoulder pain and dysfunction with athletes and working individuals. The purpose of this review is to provide a current understanding of the long head of the biceps tendon anatomy and its surrounding structures, function, and relevant clinical information such as evaluation, treatment options, and complications in hopes of helping orthopaedic surgeons counsel their patients. An understanding of the long head of the biceps tendon anatomy and its surrounding structures is helpful to determine normal function as well as pathologic injuries that stem proximally. The biceps-labral complex has been identified and broken down into different regions that can further enhance a physician’s knowledge of common anterior shoulder pain etiologies. Although various physical examination maneuvers exist meant to localize the anterior shoulder pain, the lack of specificity requires orthopaedic surgeons to rely on patient history, advanced imaging, and diagnostic injections in order to determine the patient’s next steps. Nonsurgical treatment options such as anti-inflammatory medications, physical therapy, and ultrasound-guided corticosteroid injections should be utilized before entertaining surgical treatment options. If surgery is needed, the three options include biceps tenotomy, biceps tenodesis, or superior labrum anterior to posterior repair. Specifically for biceps tenodesis, recent studies have analyzed open vs arthroscopic techniques, the ideal location of tenodesis with intra-articular, suprapectoral, subpectoral, extra-articular top of groove, and extra-articular bottom of groove approaches, and the best method of fixation using interference screws, suture anchors, or cortical buttons. Orthopaedic surgeons should be aware of the complications of each procedure and respond accordingly for each patient. Once treated, patients often have good to excellent clinical outcomes and low rates of complications.

Management of proximal biceps tendon pathology

The number of atraumatic stress fractures of the scapular spine associated with reverse shoulder arthroplasty is increasing. At present, there is no consensus regarding the optimal treatment strategy. Due to the already weakened bone, fractures of the scapular spine require a high fixation stability. Higher fixation strength may be achieved by double plating. The aim of this study was to evaluate the biomechanical principles of double plating in comparison to single plating for scapular spine fractures. In this study, eight pairs (n = 16) of human shoulders were randomised pairwise into two groups. After an osteotomy at the level of the spinoglenoid notch, one side of each pair received fracture fixation with a single 3.5 LCP (Locking Compression Plate) plate. The contralateral scapular spine was fixed with a 3.5 LCP and an additional 2.7 LCP plate in 90–90 configuration. The biomechanical test protocol consisted of 700 cycles of dynamic loading and a load-to-failure test with a servohydraulic testing machine. Failure was defined as macroscopic catastrophic failure (screw cut-out, plate breakage). The focus was set on the results of specimens with osteoporotic bone quality. In specimens with an osteoporotic bone mineral density (BMD; n = 12), the mean failure load was significantly higher for the double plate group compared to single plating (471 N vs. 328 N; p = 0.029). Analysis of all specimens (n = 16) including four specimens without osteoporotic BMD revealed no significant differences regarding stiffness and failure load (p > 0.05). Double plating may provide higher fixation strength in osteoporotic bone in comparison to a single plate alone. This finding is of particular relevance for fixation of scapular spine fractures following reverse shoulder arthroplasty. Controlled laboratory study.

/pdf/double-plating-is-associated-with-higher-fixation-strength-42kn0qpm7h.pdf

Double plating is associated with higher fixation strength than single plating in osteoporotic fractures of the scapular spine: a biomechanical study.

Stemless reverse shoulder arthroplasty: Clinical and radiological outcomes with minimum two years follow-up.

The objective of this study was to assess mid- to long-term functional outcomes in patients treated for symptomatic posterolateral instability of the elbow (PLRI) using an autologous ipsilateral triceps tendon as graft. A total of 196 patients were treated with autologous triceps tendon graft for symptomatic PLRI at single orthopedic institution from 2006 to 2013. The surgical treatment contained arthroscopic instability testing, reconstruction of the lateral ulnar collateral ligament (LUCL) and harvesting autologous ipsilateral triceps tendon as graft. The follow-up outcomes included range of motion (ROM), pain measured on a visual analogue scale (VAS), Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES) and ultrasound to evaluate the integrity of the refixation of the common extensor. A total of 178 patients (female: 73; male: 105) were available for follow-up at a mean of 91 months (range 48–144). No patient reported pain at rest; VAS during activity was 1.8 (range 0–5). The ROM decreased slightly compared to preoperative measurements. Flexion decreased significantly from 135.4 to 131.1, though still within the functional arc of motion. All but 13 patients (8.5%) were clinically stable. However, only two patients received a revision of the LUCL reconstruction due to subjective instability. The mean MEPS in the final follow-up was 91.3 (range 73–100). The mean OES was 46.5 (range 39–48). Three patients reported a pain-free clicking of the elbow. No patient complained about donor site morbidity of the ipsilateral triceps tendon. Ultrasound evaluation showed integrity of the common extensors in all patients. LUCL reconstruction using the ipsilateral triceps tendon as graft shows good to excellent mid- to long-term results in the treatment of symptomatic posterolateral elbow joint instability with a low re-instability and complication rate.

Autologous triceps tendon graft for LUCL reconstruction of the elbow: clinical outcome after 7.5 years

Several techniques for performing a tenodesis of the long head of biceps (LHB) are described. Only few outcome studies are published. This note describes a unicortical fixation via a suture plate—comparable to a distal biceps refixation-performed arthroscopically or mini-open via standard suprapectoral approach. The aim of this study is to show the clinical outcome after 6, 12, and 24 months. A consecutive series of 50 (35 male, 15 female) patients at the mean age of 49 years (range 23–75) who underwent tenodesis of the LHB were followed for 2 years. All patients were operated by a single surgeon (CS). The clinical evaluation included Constant score, Scheibel LHB score and VAS. Structural integrity of the tenodesis was checked by ultrasound control. Integrity of the tenodesis was evaluated indirectly by detecting the LHB-tendon up to the ultrasound-reflex of the button. No tendon at the button-reflex was considered as failure of the tenodesis. An independent examiner who was not the operating surgeon performed all evaluations. (MG evaluated the patients operated by CS). Mean follow-up was 29.5 (range 22–32) months. The mean pre-operative Constant Murley score (CMS) was 67.4 points (range 45–78) and increased to 84.7 points (range 51–99) after 2 years. LHB Score was 90.8 after 24 months. We identified 2 failed biceps fixations (4%). Pain relief was achieved in most patients within the first 12 weeks. After 2 years, the mean biceps flexion strength averaged 84% of the healthy arm. Tenodesis of the LHB with a unicortical suture plate is a safe fixation technique with good-to-excellent clinical results after a minimum follow-up of 2 years. Long-term follow-up is needed.

Suprapectoral biceps tenodesis using a suture plate: clinical results after 2 years

Die inverse Prothese setzt sich immer mehr im klinischen Alltag durch. Die seltene Komplikation der Acromionfraktur und deren Therapie ist bisher nur selten beschrieben. Ziel der hier vorgestellten Studie war es (1) die Inzidenz der Acromionfraktur nach inverser Prothese zu beschreiben; (2) die entsprechenden Therapieoptionen konservativ und operativ miteinander zu vergleichen. Im Untersuchungszeitraum von 2008–2014 wurden 583 inverse Schulterprothesen in unserer Klinik implantiert. In einem retrospektiven Studiendesign konnten im Verlauf 12 Acromionfrakturen diagnostiziert werden. Die ersten 6 Patienten wurden operativ mit Plattenosteosynthese versorgt, wahrend die folgenden 6 Patienten konservativ therapiert wurden. Die Ergebnisse der Therapievarianten wurden hinsichtlich Constant-Murley-Score (CS), Schmerz, Zufriedenheit und radiologischem Verlauf verglichen. Die Inzidenz der Acromionfraktur betrug 2,05 %. Das Intervall zwischen endoprothetischer Versorgung und Frakturdiagnose betrug 11,4 Monate. Der mittlere CS vor Fraktur betrug 74,2. In der operativ versorgten Gruppe (oT) betrug der CS 55,4, in der konservativen Therapie (kT) 55,3 im 4,5-Jahres-Follow-up (FU). In der Subgruppenanalyse profitierte die konservative Gruppe mehr beim Schmerz, die operative Gruppe bei der Kraft. Eine Revision in der oT war nicht notwendig. Die radiologische Durchbauung 1 Jahr nach Fraktur konnte in 5 von 6 Fallen in der oT und bei 4 von 6 in der kT nachgewiesen werden. Die Acromionfraktur bei inverser Prothese ist eine seltene Komplikation. Im Vergleich zum initialen CS zeigen sowohl konservativ als auch operativ therapierte Frakturen eine Besserung, dennoch bleiben die Ergebnisse deutlich hinter dem CS vor dem Frakturereignis.

Therapie bei Acromionfraktur nach inverser Prothese

Hidden instability could be one of the reasons for reoccurring stiffness after arthrolysis in posttraumatic elbows. Associated instability in stiff posttraumatic elbows is clinically hard to detect. Surgical treatment for instability and stiffness in the same surgical setting is challenging and has not been evaluated as of yet.
 The primary hypothesis assumes (1) the existence of a posttraumatic “stiff and unstable elbow” and (2) that coexisting instability can be detected by arthroscopic instability testing. The secondary objective was to report the midterm results after arthrolysis and ligament stabilization in the stiff and unstable elbow. From 2005 to 2015, 55 patients received arthroscopic arthrolysis of the elbow due to posttraumatic elbow stiffness at our institution. The arthroscopic instability was categorized into three grades with a switching stick: grade I (= stable), grade II (mild instability) and grade III (grossly instable). In cases of persisting instability (grade II-III), a ligament stabilization procedure was performed and all patients were followed up clinically at a minimum of 12 months. Besides ROM and clinical joint stability, PROs (patient reported outcomes) were assessed with the PREE-score (patient-rated elbow evaluation) and the Oxford-Elbow-score (OES). Furthermore, the MEPS (Mayo-elbow-performance-score) was assessed. Out of 55 cases presenting for arthrolysis, coexisting elbow instability was detected during arthroscopic instability testing in 22 cases (40%). All 22 patients received additional ligament stabilization. At final follow-up 62.7 ± 35.7 months postoperatively, 20 patients (12 men; 8 women) with a mean age of 42 ± 16.8 were available. PREE, OES and MEPS were 19.8 ± 25.3, 37.5 ± 9.8 and 80 ± 14.5, respectively. ROM improved significantly from 95° ± 29° to 110° ± 24° postoperatively (p = 0.045). Five patients required revision arthrolysis within the follow-up period (20%). One patient demonstrated persisting instability (5%). Intraoperative instability diagnostics during arthroscopic arthrolysis helps detect persisting posttraumatic instability and may provide a solid indication for a concurrent ligament stabilization procedure. This study is the first to present the postoperative results after arthrolysis with stabilization of the posttraumatic, stiff and unstable elbow. However, the results are heterogenic with 25% requiring revision arthrolysis. Therefore, the stiff but unstable elbow remains a complex clinical presentation in need of further investigations. IV

Hidden instability in posttraumatic stiff elbows

Die Ellenbogenluxation ist eine grose therapeutische Herausforderung. Obwohl es sich mit einer Inzidenz von 6–13 Luxationen pro 100.000 Einwohner um die zweithaufigste Luxation des Erwachsenen nach der Schulterluxation handelt [1], gibt es bisher kaum einheitliche Therapiekonzepte. Um eine konservative Behandlung erfolgreich durchfuhren zu konnen, bedarf es einiger Voraussetzungen, die direkt nach der Reposition und auch im Verlauf wiederholt uberpruft werden sollten. Nur unter Beachtung dieser „red flags“, kann eine konservative Therapie erwogen werden.

Ellbogenluxation: Wann und wie konservativ behandeln?

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